1) Risk for Clinically Relevant Adverse Cardiac Events in Patients with Chest Pain at Hospital Admission. Weinstock et al. JAMA: Internal Medicine 2015;175(7): 1207-1212.
a. Clinical Question: Does admitting patients to hospital convey benefit?
b. Methods & Results: Chart review. All patients admitted with trop at time 0 and time 60-420 minutes. Looked for outcome CRACE: Life Threatening arrhythmia, Inpatient STEMI, Cardiac/Respiratory arrest, death during hospitalization.
c. Author Conclusions: Found either 0.18% rate or 0.06% rate (NNT 562 or 1817). Vs NNKill 164 with medical error.
d. Limitations & Controversies: Chart review. Excluded patients with SBP < 100, HR > 100, SpO2 <95%, ECG with ischemia, LBBB (even baseline), or paced rhythm.
e. My Take Home Point: They looked for CRACE not MACE (which includes stenting, nSTEMIs, etc). I often dc pts with SpO2 at 94% or with paced rhythms or baseline LBBBB that appears unchanged. None the less, this data suggests admission likely isn’t life protecting, what seems much more important is securing clear & reliable follow up. Sometimes this requires admitting the patient.
2) Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. Kaukonen et al. New England Journal of Medicine. 2015; 372(17):1629-1638.
a. Clinical Question: How much does SIRS matter? Does it predict SEPSIS?
b. Methods & Results: Australia/New Zealand ICU database from 1st 24 hours. Pts with organ failure & infection. 12.1% of all these patients never met SIRS. Also each sequential SIRS criteria increased mortality by 13% with no specific change at 2/4.
c. Author Conclusions: Authors “challenge the sensitivity, face validity, and construct validity of the rule regarding two or more SIRS criteria…”
d. Limitations & Controversies: Data base from ICU so pts already treated, not ED patients. Also mortality dropped 36.1% 18.3% for 2+ SIRS & 27.1% 8.5% for SIRS – patients during this study.
e. My Take Home Point: SIRS happen for lots of reasons and also 1/8 Septic patients don’t have SIRS. But aggressive care clearly benefits patients decreasing mortality.
3) The First 500: Initial Experience with Widespread Use of Low-Dose Ketamine for Acute Pain Management in the ED. Ahearn et al. American Journal of Emergency Medicine. 2015;33:197- 2001.
a. Clinical Question: How does ketamine perform when rolled out in an ED as a general pain medication?
b. Methods & Results: 530 patients. 3.5% frequency of psychomimetic effects. Only 1.9% severe enough to prevent further use. Only 0.7% requiring treatment. 1.5% Hypoxia (vs 5% with hydromorphone) and 1% with emesis (vs 7% with hydromorphone). Severe side effects never occurred: Cardiac arrest, apnea, HTN emergency, laryngospasm.
c. Author Conclusions: This is a safe and effective drug.
d. Limitations & Controversies: Many hospitals, EDs, and nurses will still consider any ketamine use to be sedation until further education occurs.
e. My Take Home Point: This is the biggest study, but there are > 1000 patients reported in LDK studies for ED use. So I wrote a policy for our ED; please contact me for a copy of it.
4) Idarucizumab for Dabigatran Reversal. Pollack et al. New England Journal of Medicine. 2015;373(6):569-571. Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity. Siegal et al. New England Journal of Medicine. 2015; 373(25):2413-2424.
a. Clinical Question: Can the Novel Oral Anticoagulants (NOACs) be reversed?
b. Methods & Results: Idarucizumab in a phase III trial reverse anticoagulation in patients with life threatening bleeding or needing emergent surgery. Andexanet Alfa in a phase II trial reversed markers of bleeding in healthy volunteers taking either apixaban or rivaroxaban. But only worked until 2 hours after stopping bolus or drip.
c. Author Conclusions: Idarucizumab study was stopped early due to finding benefit and is FDA approved as Praxbind. Andexanet has gone to phase III trial.
d. Limitations & Controversies: Idarucizumab was a fairly small trial with 22/90 patients who were later revealed to be sub-therapeutic on dabigitran.
e. My Take Home Point: Idarucizumab is now FDA approved and you will use it. Andexanet Alfa is coming soon to a pharmacy near you.
5) Transfusion of Plasma, Platelets, and Red Blood Cells in a 1:1:1 vs a 1:1:2 Ratio and Mortality in Patients With Severe Trauma. Holcomb et al. JAMA. 2015; 373(25):2413-2424.
a. Clinical Question: Which is better 1:1:1 or 1:1:2 ratio? Platelets:Plasma:PRBCs
b. Methods & Results: Powered for a 10% mortality difference. Found only 4%, this was not statistically significant.
c. Author Conclusions: Suspected benefit. Also all mortality benefit found in the first 3 hours which would fit with helping achieve hemostasis. Subgroup analysis showed that hemostasis was achieved faster with 1:1:1 and also that the 1:1:2 group was postintervention given extra platelets & plasma and eventually caught up in blood product ratios.
d. Limitations & Controversies: There was no statistically significant mortality difference. The 1:1:1 group got platelets before anything whereas the 1:1:2 group got 9 units of blood product before platelets were given. So were we testing platelets or ratios?
e. My Take Home Point: 1:1:1 does look better, but the literature would clearly & strongly support either practice.
Written by Garreth Debiegun, MD
Edited and Posted by Jeffrey A Holmes, MD
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